Guidelines
ASMBS/IFSO Guidelines for Metabolic and Bariatric Surgery
In November 2022, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued updates to the 1991 National Institutes of Health (NIH) guidelines for bariatric surgery. [10] Recommendations included the following:
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Metabolic and bariatric surgery (MBS) is recommended for all individuals with a body mass index (BMI) higher than 35 kg/m 2, regardless of the presence, absence, or severity of comorbid conditions.
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MBS should be considered for individuals who have metabolic disease and a BMI between 30 and 34.9 kg/m 2.
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In the Asian population, BMI thresholds should be adjusted so that a BMI exceeding 25 kg/m 2 suggests clinical obesity. MBS should be offered to Asian individuals with BMIs higher than 27.5 kg/m 2.
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Long-term results of MBS consistently demonstrate safety and efficacy.
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MBS should be considered for appropriately selected children and adolescents.
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DSS-II Guidelines for Bariatric/Metabolic Surgery in Type 2 Diabetes
In June 2016, the 2nd Diabetes Surgery Summit (DSS-II), an international consensus conference, issued the following global guidelines regarding the benefits and limitations of bariatric/metabolic surgery for type 2 diabetes mellitus [12] :
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Metabolic surgery should be a recommended option to treat type 2 diabetes mellitus in appropriate surgical candidates with class III obesity (BMI ≥40 kg/m 2), regardless of the level of glycemic control or complexity of glucose-lowering regimens, as well as in patients with class II obesity (BMI 35.0-39.9 kg/m 2) with inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy
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Metabolic surgery should also be considered to be an option to treat type 2 diabetes in patients with class I obesity (BMI 30.0-34.9 kg/m 2) and inadequately controlled hyperglycemia despite optimal medical treatment by either oral or injectable medications (including insulin)
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All BMI thresholds should be reconsidered depending on the ancestry of the patient; for example, for patients of Asian descent, the BMI values above should be reduced by 2.5 kg/m 2
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Metabolic surgery should be performed in high-volume centers with multidisciplinary teams that understand and are experienced in the management of diabetes and gastrointestinal surgery
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Ongoing and long-term monitoring of micronutrient status, nutritional supplementation, and support must be provided to patients after surgery, according to guidelines for postoperative management of bariatric/metabolic surgery by national and international professional societies
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Metabolic surgery is a potentially cost-effective treatment option in obese patients with type 2 diabetes; the clinical community should work together with health care regulators to recognize metabolic surgery as an appropriate intervention for type 2 diabetes in people with obesity and to introduce appropriate reimbursement policies
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ESPGHAN Guidelines for Bariatric Surgery in Children
In January 2015, the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) published a position statement on bariatric surgery for severely obese children and adolescents, which provided the following guidelines [11] :
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Consider bariatric surgery in "carefully selected" patients with a body mass index (BMI) higher than 40 kg/m 2 who have severe comorbidities (eg, nonalcoholic fatty liver disease [NAFLD]) or in those with a BMI higher than 50 kg/m 2 who have milder comorbidities
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Additional factors to consider in deciding whether a child or adolescent should undergo bariatric surgery include physical and psychological maturity, personal desire to undergo the procedure, previous attempts at weight loss, and ability to adhere to follow-up care
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Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and sleeve gastrectomy are the most widely used procedures in pediatric obesity, but their use is associated with subsequent nutritional deficiencies; temporary intragastric devices could represent a better option for initial treatment in pediatric populations
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Current evidence suggests that bariatric surgery can decrease the grade of steatosis, hepatic inflammation, and fibrosis in NAFLD
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Uncomplicated NAFLD is not an indication for bariatric surgery
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Roux-en-Y gastric bypass is considered a safe and effective option for extremely obese adolescents, as long as appropriate long-term follow-up is provided
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Laparoscopic adjustable gastric banding has not been approved by the FDA for use in adolescents and therefore should be considered investigational
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Sleeve gastrectomy and other types of weight loss surgery that have grown increasingly common in adults must still be considered investigational
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Media Gallery
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Laparoscopic Roux-en-Y gastric bypass.
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Adjustable gastric banding.
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Sleeve gastrectomy.
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Long Roux-en-Y gastric bypass.
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Biliopancreatic diversion with duodenal switch.
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Progression of surgical techniques, with open surgery in first image and single-incision transumbilical laparoscopic surgery in third illustration.
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